The scale-up of lifelong antiretroviral therapy (ART) has transformed the HIV epidemic in sub-Saharan Africa, substantially reducing mortality while increasing the number of people requiring long-term HIV care. In Malawi, as in many high-burden settings, differentiated service delivery (DSD) models have been adopted to improve the efficiency and sustainability of HIV services by tailoring care to client needs. However, the expansion of DSD has also increased demands on monitoring and evaluation systems, documentation processes, and healthcare worker workloads. Mobile health (mHealth) interventions have been proposed as a means of addressing these challenges, yet evidence regarding their effectiveness and contribution to health system efficiency when integrated into routine DSD programs remains limited. This dissertation examines whether and how mHealth strengthens DSD models for HIV care in Malawi by improving client engagement in care and health system efficiency. Using Lighthouse Trust, a large HIV service provider, as a case study, the research evaluates two mHealth interventions implemented within routine HIV programs: an interactive two-way text messaging (2wT) system supporting clients newly initiating ART and the Community-based ART Retention and Suppression (CARES) mobile electronic medical record application supporting community-based ART delivery for clinically stable clients.
A mixed-methods approach was used across four empirical studies. A randomized controlled trial demonstrated that 2wT improved early engagement in care by increasing on-time attendance at scheduled visits during the ART initiation period, although no significant differences were observed in six-month retention or viral load suppression. A subsequent cost-effectiveness analysis found that while the intervention incurred modest additional costs, its economic performance improved substantially when implemented at scale. Qualitative findings from healthcare workers using the CARES application indicated high perceived usefulness and acceptability, particularly through improved access to client information, reduced reliance on paper-based records, and enhanced continuity of care. A complementary cost–benefit analysis of CARES over a ten-year period demonstrated that digital documentation reduced time spent on routine administrative tasks and generated efficiency gains that exceeded development and maintenance costs.
The dissertation demonstrates that mHealth can strengthen differentiated service delivery by improving early engagement in care, reducing routine documentation burdens, and enhancing continuity of service delivery. However, these benefits are not automatic and depend on alignment with existing workflows, organizational structures, and health system capacity. Rather than reducing clinical inputs or substantially lowering costs, mHealth-enabled DSD supports the sustainability of HIV programs by improving efficiency and resource utilization. The findings suggest that digital tools can contribute to HIV epidemic control when they are integrated into routine service delivery and designed to support both clients and healthcare workers within resource-constrained health systems.
